A client is admitted for major depression. The client has stated that nothing seems to bring him pleasure anymore. What should the nurse expect to find during the assessment?
Changes in sleep pattern, fatigue, and grandiose mood.
Depressed mood, guilt, and pressured speech.
Difficulty focusing, feelings of helplessness, and flight of ideas.
Anhedonia, feelings of worthlessness, and difficulty focusing.
The Correct Answer is D
Choice A reason: Grandiose mood is a feature of mania, not depression. While sleep changes and fatigue are consistent with depression, the presence of grandiosity makes this option incorrect.
Choice B reason: Pressured speech is a symptom of mania, not depression. Depression is characterized by slowed speech and psychomotor retardation rather than rapid, pressured communication.
Choice C reason: Flight of ideas is a hallmark of mania, not depression. Depression involves slowed thought processes, difficulty concentrating, and feelings of helplessness, but not rapid shifts in thought.
Choice D reason: Anhedonia (loss of pleasure), feelings of worthlessness, and difficulty focusing are core symptoms of major depression. This option directly matches the client’s report and expected findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:This is correct because sudden cessation of alcohol after prolonged heavy use can cause life-threatening withdrawal symptoms such as seizures, delirium tremens, and severe autonomic instability. Medical supervision and pharmacological support (e.g., benzodiazepines) are necessary to ensure safety during detoxification.
Choice B reason:While supportive, this does not address the immediate danger of stopping alcohol suddenly. Motivation is important, but the nurse must prioritize safety and emphasize medical management of withdrawal.
Choice C reason:This is incorrect because withdrawal symptoms can be severe and potentially fatal. Rest alone is not sufficient, and medical intervention is necessary.
Choice D reason:This is incorrect because it minimizes the severity of alcohol withdrawal. Headaches and anxiety are possible, but seizures and delirium tremens are more serious risks. Acetaminophen and rest are inadequate management strategies.
Correct Answer is B
Explanation
Choice A reason:Overprotective parenting may contribute to dependency issues or difficulty with autonomy, but it is not considered the strongest predictor of substance abuse. While it can influence coping skills, it does not directly correlate with addiction risk as strongly as parental substance abuse.
Choice B reason:Having a parent who is an alcoholic is the most significant risk factor. Genetics play a major role in substance use disorders, and children of alcoholic parents are at higher risk due to both hereditary predisposition and environmental exposure. Modeling of maladaptive coping strategies and normalization of substance use further increase vulnerability.
Choice C reason:Strict discipline can contribute to rebellion or emotional distress, but it is not the most significant risk factor compared to direct exposure to parental substance abuse. While harsh parenting may increase psychological stress, it does not carry the same genetic and environmental impact.
Choice D reason:Being raised in an urban area may expose individuals to more opportunities for substance use, but location alone is not a strong determinant. Environmental factors can contribute, but they are less predictive than familial substance abuse history.
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